‘Not going to prevent a third wave’: Epidemiologist Isaac Bogoch on Ontario’s vaccine rollout

TVO.org speaks with the infectious-disease researcher about Phase 2, variants of concern, and the kind of national public-health guidance Canadians need now
By Sarah Trick - Published on Mar 15, 2021
Isaac Bogoch is a member of the province’s vaccine task force. (Courtesy of Isaac Bogoch)

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Ontario’s vaccination campaign is finally ramping up. With the launch of the provincial booking portal on March 15 and thousands more vaccine doses set to arrive in the coming days, more and more vulnerable people will be able to be vaccinated. Unfortunately, experts say, this won’t come in time to avert a third wave driven by variants of concern.

TVO.org speaks with Isaac Bogoch, an epidemiologist and infectious-disease researcher who’s a member of the province’s vaccine task force, about vaccine prioritization, the Phase 2 rollout — and the kind of public-health guidance Ontarians need now.

TVO.org: I wanted to start by asking about the launch of the provincial portal for booking vaccine appointments. How do you see this tool changing the rollout over the next couple of weeks?

Isaac Bogoch: I think it’s just going to make it more efficient. We need three key ingredients to really ramp vaccines up. Number one, of course, is you need the actual vaccines. And we know that Canada is really getting a significant influx of vaccines starting next week. We currently have a lot right now, but it’s just going to get better and better and better. The second component is a system through which people can effectively sign up for the vaccines. Now, obviously there’s going to be some growing pains, as expected, but I imagine this will be ironed out pretty quickly. The third thing is the public-health units’ ability to efficiently administer the vaccines that they get, and I have a high, high degree of confidence that they’ll be able to do that as well.

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We’re really set up to massively scale up the vaccine program. People can now start booking, and then many of the mass-vaccine clinics are going live this week throughout the province. So we’ll significantly be picking up the pace of vaccination this week.

TVO.org: So the big issue, or the biggest ongoing concern, is the race against the variants versus the pace of the vaccination.

Bogoch: Yeah, but, I mean, if it’s framed like that, the variants are going to win, right? The pace of vaccination is not going to prevent a third wave. The pace of vaccination can help prevent the most vulnerable among us from getting sick. But it’s not going to prevent a third wave.

For example, we vaccinated over 90 per cent of the residents of long-term care. That’s extremely important, because those individuals really represent anywhere from 50 to 80 per cent of the deaths that we’ve had. As we do see a third wave emerging, we know that the most vulnerable among us will have some protection. But that itself won’t protect us from having a third wave.

We know there are still a lot of people who are vulnerable to getting this infection and having a severe infection that are not yet vaccinated. We also have to remember that, even after people are vaccinated, they won’t really start to realize the benefits of the vaccine for about two weeks after their first dose. So we’re still a ways away from protecting vulnerable individuals in Ontario. This will not be fast enough to protect us from a third wave. It will protect many, but not all vulnerable individuals in Ontario.

TVO.org: That actually leads me to the next thing that I wanted to ask about. I’m curious whether you can share any insight about how the vaccine task force came to the decision about whom to prioritize in Phase 2 — and why?

Bogoch: It really boils down to two key measures. Let’s look at this through a lens of equity, and let’s look at this through a lens of data. So, essentially, who is at greatest risk of having a severe infection if they’re infected, and who’s at greatest risk of getting infected?

Now, there is an ethical framework for prioritization, and part of that ethical framework is really to prevent severe illness and death. So we have to prioritize people who are going to get really sick and, ultimately, succumb to this illness. Who is that? I mean, there are lots of risk factors for severe illness, but the one that blows all of the rest out of the water is age. Age is by far the most significant risk factor. When you look at the Phase 2 protocols, you can see that age is prioritized.

Right now, the focus is on vaccinating those who are over the age of 80; then it will go down to those who are over the age of 75. It works its way down in five-year increments. Eventually we start factoring in other risk factors for either infection or severe outcome. For example, there are people with certain medical conditions that, if they were to be infected, are at risk of severe outcomes, absolutely. So those individuals are also given priority. But, of course, not all medical conditions are the same. Some medical conditions would be higher up during Phase 2, whereas others are still prioritized above the general population but aren’t given the same degree of priority as certain medical conditions, like blood cancers or organ-transplant patients.

If you look at who is prioritized — and how they’re prioritized — in Phase 2, you can see that this is really done through a lens of data and equity.

One other thing — sorry, I missed one other huge point. We talked about age, but it’s also important to look at the social determinants of health. And I think the social determinants of health and equity really drive another major decision in prioritization. If we look at Ontario, for example, there are people who may be 50 years of age, in certain area codes, who are at the same risk of death as 80-year-olds in other area codes. And we know that the virus has disproportionately impacted lower-income neighbourhoods and racialized neighbourhoods. And what we’ve ended up doing was saying in the Phase 2 rollout, we can set a lower age threshold for certain area codes, because we know that the risk of death in those area codes is greater for that age group. It’s just another way that you can build equity into the vaccine rollout program.

TVO.org: Can you share a bit more about how you made the decision to prioritize certain groups within the priority groups?

Bogoch: If you look at the data, there’s no shortage of good data for risk factors for infection and risk factors for severe infection. And it’s interesting, because a lot of the data tells the same story, right? There are a lot of risk factors for severe infection, but age truly reigned supreme — to the point that, if you go on the Public Health Agency of Canada website, there’s really good Canadian data as well. Sixty-nine per cent of deaths in Canada are people over the age of 80; 19 per cent of deaths in Canada are people between 70 and 79. And 7.7 per cent of deaths are in people age 60 to 69. So over 95 per cent of the deaths related to COVID-19 in Canada are in people over the age of 60.

TVO.org: One of the things that got a little bit of play, I think it was last week, was that people with high-risk medical conditions weren’t necessarily going to be asked to provide proof of having a high-risk condition. Is this still the case? And if so, why? And is there a concern that people could jump the queue?

Bogoch: There are a few statements that don’t entirely seem related, but are related. Number one, we have different vaccines available to us in the country. Many of the vaccines are better suited for mass-vaccine clinics. Pfizer is a vaccine that is best suited for mass-vaccine clinics. Yeah, you can get Moderna into pharmacies, into primary care. And, certainly, AstraZeneca is very good for pharmacies and primary care. But Pfizer is really a vaccine that’s best suited for a mass-vaccine clinic.

The second point, that’s somewhat related, is that primary care is best suited to help identify patients who would meet criteria for vaccination based on underlying medical conditions. Primary care knows their patients. Primary care now has a growing role in vaccinating individuals in their clinics. It’s not widespread, but it’s a growing role. And they’ll certainly be helpful in adjudicating who can be vaccinated based on pre-existing medical conditions.

The third point is, will there be people who jumped the queue? Yes, of course, it’s not going to be perfect. When we’re vaccinating a province of 14 million people, you know, it’s not going to be right 100 per cent of the time. But I think with a growing role for family primary care to vaccinate individuals in their own clinics, we will have a better means to adjudicate when those with underlying medical conditions can be vaccinated.

Just thinking out loud: Can you imagine having someone with an underlying medical condition go to a mass-vaccine site and having someone say, “Show us evidence that you’ve had a lung transplant?” Are you supposed to show them the scars on your chest where they did the surgery? Like, that doesn’t make any sense. The other thing that doesn’t make sense is, what are you going to do? Ask people to go to their primary-care provider to get a note that says that they’re in this or that phase of vaccination? Nobody wants that. Primary care is busy enough doing their clinical work and hopefully vaccinating that they shouldn’t be in a position to start writing notes for all their patients saying that they meet criteria for vaccination.

TVO.org: Can you talk a bit about the pilot program that has allowed eligible people between the ages of 60 and 64 to get AstraZeneca shots?

Bogoch: Yeah. I hate how this was billed as a pilot program. Like, there’s nothing pilot about this. This is the vaccine rollout. And I’m not pointing fingers at you — I just don’t understand why the province keeps calling it a pilot.

TVO.org: Oh, I thought it really was just a limited pilot program.

Bogoch: The whole plan is to learn from this and expand it. Right? We’re going to get more AstraZeneca. We’re going to get Johnson and Johnson. We’ve had the ability to mobilize Moderna into other settings, like pharmacies and primary care. I just don’t understand why you’d call it a pilot when this is the program. This is rolling out — like, we’re doing it. The whole goal is to expand vaccination in multiple venues, including primary care and pharmacies.

I think it’s going so far, so good. Certainly, we’re hearing that people are signing up, they’re getting the vaccine — this seems to be going well.

TVO.org: Yeah, but if age is the biggest risk factor, why are we diverting resources to this group at this point?

Bogoch: Oh, because the NACI guidance said that you shouldn’t give AstraZeneca to those over the age of 65. So most of the provinces aligned with the NACI guidance. Imagine this: you’ve got a vaccine. Clinical trials demonstrated efficacy and safety. There’s real-world data that is emerging globally also demonstrating effectiveness and safety. And Canada gives it conditional approval, and then we’ve got access to it. But the National Advisory Committee on Immunization said it should be given to people under the age of 65. So if you’re a province, and you have access to this vaccine, how do you get this into people’s arms?

What many provinces said was, you know, okay, we get that people over the age of 60 are at greater risk for COVID-19. So we’re going to give it to people between the ages of 60 and 65. I think that’s very reasonable. I mean, the other way is you could give it to other NACI-recommended Phase 1 individuals, such as Indigenous populations or health-care providers. As long as you’re using it in a high-priority group, I think you’re doing something right. So, yeah, everyone’s just sticking to the NACI guidance, except for Quebec. Quebec said, we’ve seen the real-world data that’s emerged from Scotland and from England. And we recognize that the real-world data suggests that it does work well in people over the age of 65. So they’re giving it to people over the age of 65.

In fact, France and Germany, earlier on, weren’t giving it to people over the age of 65. And with the real-world data that was emerging from the United Kingdom, they’ve shifted course, and they’re now giving it to people over the age of 65. I think what’s going to happen is NACI is going to revisit that data and address and evaluate the real-world data. And I wouldn’t be surprised if NACI changes their mind and then recommends it to people above 65 as well, but I’m not entirely sure what they’ll do.

TVO.org: I did want to ask about the Ontario strategy to offer as many first doses as possible and to delay the second dose for a lot of people. I know people have gone over a lot of the reasoning about this. But since that announcement, we’ve gotten a lot more vaccines than we expected to have. So is this still the plan?

Bogoch: I think it’s important to recognize why this plan came to be. Just so we’re clear, this isn’t a task-force issue. This was an issue made by the Ministry of Health and by public health. We have nothing to do with this decision, but I can explain it.

The National Advisory Council or Committee on Immunization came out with a document saying that you can space the vaccines out by four months. Now, this got a lot of pushback, because if you look at data available, it’s clear that you can stretch them out by two months — there’s recent data that suggests that you could probably stretch out that second dose by three months. But it’s not entirely clear how they got to a four-month recommendation.

I totally see, from a public-health standpoint, how giving more first doses in a shorter period of time could benefit a population. On the other hand, there’s now emerging data demonstrating that people on the older end of the spectrum — and people with compromised immune systems — may not mount the same degree of an immune response to a single dose, and perhaps waiting for four months isn’t the best approach. I think the provinces are currently digesting that information; I hope NACI is also currently digesting that information. And perhaps spacing out the doses is safer in younger or healthier populations compared to older populations or immunocompromised populations. And I imagine that they’ll look at this data and perhaps revisit spacing out vaccines to four months for everybody. But, again, I don’t know what they’re going to do.

TVO.org: Do you know whether there’s going to be guidance for what you can do if you’re fully vaccinated versus what you can do if you’re partially vaccinated?

Bogoch: Again, I don’t know. You would want that — that’s extremely important — because we’re going to be entering a period where some of us are fully vaccinated, some of us have had one dose of a two-vaccine series, and some of us are not vaccinated just yet. And it would be extremely helpful to have a playbook on what’s acceptable and appropriate behaviour.

The CDC, for example, came up with this very recently, and it was very reasonable — right, like, people who are two weeks post completing their vaccine series can get together with other fully vaccinated individuals and small groups, but you don’t have to physically distance and wear a mask. Or, for example, if grandchildren aren’t vaccinated but are low-risk, grandparents can spend with time and hug them. But we’re in a different situation in Canada, because many people will have only one dose of a vaccine; we know that it provides some protection but not full protection. We know that it reduces your risk, still, of hospitalization and death. But it’s not entirely clear what the recommendation is going to be for individuals who have just had one dose of the vaccine. We need clarification on this quickly, because this question is going to continue to arise.

TVO.org: Right, I know a few grandparents, and I can see people being on board with the spacing of the doses until you tell some grandparents that no, you’ll have to wait to hug your grandkids for four more months, sorry.

Bogoch: Right — like, it’s going to be August. Really? We need a national strategy and national guidance on this because this is going to come up quickly. It already is coming up, and everyone’s going to have their own opinions and their own risk threshold and risk tolerance and risk perception. And that’s okay, but it would be helpful to have national guidance on what they feel is appropriate as well.

TVO.org: I hadn’t thought of that, because I live in Ottawa. And if I am in Ottawa, and I can’t see a friend because I’ve gotten only one dose, whereas my friend lives over the bridge in Gatineau and the Quebec guidance is different, I could see that creating some confusion and anger really fast.

Bogoch: Yeah, we need some guidance — just like, “Hey, Canada, guess what? We’re going to be in this very strange period of time for a few months where some people aren’t vaccinated, some people are fully vaccinated, and some people are partially vaccinated. Here’s some simple guidance as to what we think appropriate behaviour is.” I think that’d be very, very helpful. I have my own opinions. But that’s based on my own understanding of the data and factored in with my own risk threshold and risk perception. It’s going to be different for everybody. So some national guidance would be extremely helpful.

This interview has been condensed and edited for length and clarity.​​​​​​​

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